A nurse on a medical-surgical unit is performing medication reconciliation for a newly admitted client. Which of the following actions should the nurse take?

Compare the medication label to the provider’s prescription on three occasions before administration.

Compare the client’s list of home medications to the admission prescriptions written for the client.

Administer medications to treat a condition to the actual prescriptions.

Ensure the medication is administered within 3 hours of the scheduled time.

Answer and Explanation

The Correct Answer is B

Choice A reason: Comparing the medication label to the provider’s prescription three times is a safety step during administration, not reconciliation. Reconciliation verifies the client’s home medications against new orders to prevent errors like omissions or duplications. This action occurs post-reconciliation, focusing on administration accuracy, not the initial verification of the medication list.
Choice B reason: Medication reconciliation involves comparing the client’s home medication list to admission prescriptions to ensure continuity and accuracy. This process identifies discrepancies, such as missed medications or incorrect doses, preventing adverse drug events. It requires verifying with the client or family and cross-checking provider orders, making it the cornerstone of safe transitions in care settings.
Choice C reason: Administering medications to treat a condition to the actual prescriptions is unclear and not part of reconciliation. Reconciliation focuses on verifying and documenting medications, not administering them. This option does not align with the systematic process of ensuring all medications are correctly prescribed upon admission, making it incorrect.
Choice D reason: Ensuring administration within 3 hours of the scheduled time relates to medication administration protocols, not reconciliation. Reconciliation verifies the accuracy of the medication list before administration. This step is about timing, not the verification process critical to preventing errors during care transitions, rendering it irrelevant to the task.

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Correct Answer is B

Explanation

Choice A reason: Nurses can witness advance directives in many settings, depending on state laws, so stating they cannot is inaccurate. This response dismisses the client’s request without providing guidance, making it incorrect and unhelpful for addressing their wishes.
Choice B reason: Including the client’s desire for advance directives in the medical record ensures their wishes are documented and respected. This aligns with the Patient Self-Determination Act, facilitating care planning, making it the correct and supportive response.
Choice C reason: Stating the client’s name can be removed from advance directives is confusing, as directives are personal and revocable, not about name removal. This response is inaccurate and irrelevant to the client’s request, making it incorrect.
Choice D reason: There is no universal age requirement of 21 for advance directives; competent adults (typically 18+) can create them. This statement is incorrect and restrictive, misinforming the client about their rights, making it inappropriate.

A. The lactation amenorrhea method is effective for planned contraception up to 12 months postpartum. B. Place the transdermal contraceptive patch on your upper arm or back. C. You can continue to use the same diaphragm you used before pregnancy. D. Start oral contraceptives immediately after delivery to ensure effectiveness.

Correct Answer is B

Explanation

Choice A reason: The lactation amenorrhea method is effective only up to 6 months postpartum, and only if exclusive breastfeeding and amenorrhea are maintained. It is not reliable for 12 months, so this statement is inaccurate, making it incorrect for contraception teaching.
Choice B reason: Placing the transdermal contraceptive patch on the upper arm or back ensures proper adhesion and absorption. This aligns with manufacturer guidelines for effective contraception, making it a correct and appropriate instruction for postpartum clients seeking reliable methods.
Choice C reason: A diaphragm used before pregnancy may no longer fit due to pelvic changes post-delivery. It requires refitting 6 weeks postpartum, so continuing use without adjustment is ineffective and risky, making this incorrect.
Choice D reason: Starting oral contraceptives immediately after delivery is not recommended, especially for breastfeeding mothers, due to risks like reduced milk supply or thromboembolism. Initiation typically begins 3-6 weeks postpartum, making this incorrect and unsafe.

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A nurse on a medical-surgical unit is performing medication reconciliation for a newly admitted client. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who asks for information about advance directives and states, “I want to make sure my wishes are respected.” Which of the following responses should the nurse make?

Correct Answer is B

Explanation

A nurse is providing teaching to a client who is postpartum and interested in information about contraception. Which of the following instructions should the nurse include?

Correct Answer is B

Explanation

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